Not a subcriber yet? Why the heck not?By subscribing, you can...

Subscribe Now

If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the Resuscitation and Critical Care goodness.

This Post was by the EMCrit Crew, published
4 years ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.

13

Comment Here

Role

7Comment threads

6Thread replies

0Followers

Most reacted comment

Hottest comment thread

7Comment authors

Recent comment authors

Role

newestoldestmost voted

Guest

Sean Marshall

I really enjoyed this podcast, thanks gents!
My role in procedural sedation is typically being a dedicated set of eyes and hands for airway management and vital signs monitoring. Keeping the pt safe while the doc pokes, prods and pulls. Knowing more about the idiosynchronies of these drugs for amnesia, apnea and hypotension helps me communicate more wisely in this role.

One question: I have seen mixed success with Ketamine monotherapy for PSA as more docs seem to be trying it. The problem being the pt dissociates but does not necessarily relax, and sometimes squirm around quite a bit… Great conditions for my role but lowsy for a lot of procedures. Do you recommend Ketamine alone for PSA?

Vote Up0Vote Down Reply

3 years ago

Guest

Paddy Golden

Thanks for an excellent podcast! One thing i think anaesthetics do well and in emergency we do relatively poorly is giving “pre-med” prior to procedural practice. Previously, i have given single agent one time dosing. Recently I ahve changed to universally giving low dose analgesic and anxiolytic 5-10 mins before starting (eg 1mg Midazolam, 50mcg fentanyl)and assessing response. I usually repeat it about 2 mins before starting depending on response to initial dose . I find this has significant benefits 1. It reduces the dose needed to overcome the inevitable anxiety component – which may be significant, resulting in decreased dosing of primary agent 2. The primary agent dose is easier to guage – especially propofol, which can be difficult to predict – with this method i have essentially halved the dose with similar effect 3. Patient satisfaction is improved – most patients have full amnesia, but also are more pain free at the time. I find that repeat dosing with propofol can be problematic, as occasionally you may use a large dose, but “not quite get there”. Due to better guaging initial dose, I haven’t found this problem with this approach. Do you think we underutilise pre-procedural both anxiolysis… Read more »

Vote Up0Vote Down Reply

3 years ago

Guest

Brad Stone MD

I am an Anesthesiologist and enjoy listeining to these ED podcasts. I have a couple points based on my understanding.

Retrograde amnesia (lack of recall of events that occur before the medication is given) is controversial and not thought to occur regularly with any medication. Head injury will do it though. Antegrade amnesia is produce by propofol and midazolam.

Deep sedation is purposeful response to painful or repeated stimulus, where genereal anesthesia is no purposeful response (see ASA sedation continuum). It seems you prefer no response to painful procedures such as chest tube insertion, so you are aiming for general anesthesia.

thanks, Brad. Yes clearly what we want for a hip dislocation or similar is general anesthesia; but we are precluded from calling it that for the reasons of politics.

Vote Up0Vote Down Reply

3 years ago

Guest

Javad Keyhani

Dear Scott,
Javad Keyhani Rural ER from western Minnesota. I was the person who saw Jim Minor speak and suggested the interview. Thank you so much for doing it! You are awesome. What did you think of his response? It was similar to the lecture I attended. I took it as “in critically ill patients, when you need to do a procedure, focus on the perfusion over the pain and sedation. If you make perfusion the goal then they are more likely to survive.” That is not to say that you ignore it but make it the second goal after perfusion. In the lecture I believe he specifically said to be careful of too many opioids in the setting of intubation the critically ill/head injured patient. This sounded really different from how I understood your approach, which sounded very pain centered. I certainly don’t want to torture my patients but if it does turn out that being more conservative improves meaningful survival the. I am for it. Thanks again!!!

Well, not quite. Jim and I actually parsed what sparked your original comment during the lecture you had heard. Nothing to do with opioids; Jim’s comments revolved around post-intubation sedation, primarily propofol but analgesics as well immediately post-tube. Here is our discussion of the topic.

Vote Up0Vote Down Reply

3 years ago

Guest

Brad Stone MD

See section at 4:30. You refer to absence of recall early after bolus propofol and describe this as retrograde amnesia. This is antegrade amnesia. No pharmaceuticals give reliable retrograde amnesia – absence of recall of events that occur before the medication is given.

I think we may be referring to two different areas of his research. I was referring to a part in his lecture talking about procedures in the critically ill patient where he said that aggressive pain control sometimes lead to worse perfusion and possibly worse outcomes. I will try to see my if he would clarify that and I hope I am misquoting him. This is pretty far afield for me coming from very rural ER but we do get the occasional critical patient and the teaching that you and Jim do is very helpful. Thanks again!

Thanks for this podcast. I really enjoyed it. I actually came back and listened to it again after an event in the ED. I have been practicing 16 years, and ketamine has been part of my practice for children this entire time. I have only recently started using it in adults, preferring propofol as my go to agent in most settings. I use intermittently for pain control as well. I had an episode of apnea in an adult who I gave ketamine to for a wrist reduction (I avoided propofol because he was already in an Aspen collar). Things were going great for about 2-3 minutes, then the reduction, and then he dropped his sats quickly. With a touch of bagging and a lot of stimulation he came right back up but I had never really anticipated that kind of response. Jim Miner mentions apnea related to ketamine only briefly in this but it has really gotten me curious (or paranoid, however you want to slice it). Two questions if you have time. (ok, actually 3) 1) Is apnea with ketamine solely related to rate of infusion? 1.2) Is 1-2 minutes what you go with for rate of administration IV?… Read more »